Mentally preparing for leaving lockdown – Expert Reaction

Tomorrow New Zealanders will reach the half-way point of the four-week-long Level 4 restrictions.

Today, the Ministry of Health launched two campaigns to provide mental health and parenting support amidst the unprecedented lockdown conditions.

The SMC asked experts to comment on how New Zealanders can mentally prepare for the uncertainty of what their daily lives might look like in the weeks ahead, and how the lockdown has had an impact on mental health services.

Jacqui Maguire, Registered Clinical Psychologist, comments:

“As we arrive at the designated Level-4 halfway line, the government has praised our collective effort in adhering to public health guidelines, indicating the national lockdown may be succeeding. Positive reinforcement is a psychological motivator to continue directed self-isolation behavior, and realistic optimism boosts physical and mental health and assists active coping. However, it is important we do not become overconfident or ‘Pollyanna hopeful’, as this could cause a decline in behavioural adherence and subsequently lead to extended isolation.

“Until the government announces the timeline for transitioning out of Level-4, New Zealanders must hold the possibility that our national lockdown could be extended. This is psychologically important, as research has demonstrated unexpected quarantine extensions can have a significant negative impact on people’s mental health and wellbeing. In particular, exacerbating any sense of frustration or demoralisation.

“New Zealanders must hold dual focus as we continue forward: staying well in isolation whilst preparing for reintegration into society. Adjusting our coping strategies to fit isolation living (e.g. using Zoom for connection) without forming lasting habits that undermine human need for physical connection. Holding perspective (‘this too shall pass’) without crossing days off the calendar. Being hopeful without overconfident. We need the government to continue being efficient in their planning and transparent in their communication to support our efforts and protect our mental health.”

No conflict of interest.

Dr Christopher Gale, Consultant Psychiatrist and Senior Lecturer, University of Otago, comments:

“Over the first week of lockdown, the mental health services have been redesigning how they interview so that the social distancing rules can be kept, and each service has been in the process of setting up work bubbles. However, there have been some challenges. Firstly, many of the most disabled and seriously mentally ill do not have access to the internet – including smartphones, which means contacting them by video conference is difficult. Secondly, the services are limiting travel, when often rural and remote clinics have visiting medical, psychological and nurse practitioner cover. And thirdly, the social stress we are experiencing has led to an increase in use of emergency services and patient and/or whānau aggression towards health staff.

“If the lockdown continues, we will need to swing from setting up distancing and concentrating on crisis services to helping and following the bulk of people who have serious mental illness who remain stable but need support to keep so. This requires regular reviews and talking therapy. There will be a further increase in the use of videoconferencing and teleconferencing. From what we have learned so far, this is a slower method of working than the usual clinics are, and it is very unlikely that we will be able to increase the number of staff we have: there is already a shortage of psychiatrists, mental health nurses, psychologists and allied health workers within most if not all DHBs and the usual means of correcting this – immigration of nurses and doctors from other countries – will not be feasible with multiple border closures.

“In the United Kingdom, there is a concern that the rationing they have will cause moral injury for healthcare workers. This was described by Neil Greenberg in the 26th March British Medical Journal as ‘the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code’. Moral injury is not a mental illness, but those who develop moral injuries are likely to experience negative thoughts about themselves or others, as well as intense feelings of shame, guilt, or disgust.

“There are ongoing needs for people with serious illnesses that are being de-prioritized in this emergency, generally with good reasons. But the planners who make such decisions are not the doctors who have to inform those who are suffering and need help that they will not be getting what they require. We need to be having truthful discussions about this. We should not pretend that these conversations are kind, but they need to be wider than doctors reading medical journals, or health care planners.”

No conflict of interest.

Dr Dougal Sutherland, Clinical Psychologist, Victoria University of Wellington and Umbrella Health, comments:

“The biggest challenge facing the country over the next two (or more) weeks is how to ‘keep the faith’ and remain in lockdown. Thus far, anxiety has driven much of our behaviour, as we stay home through fear of getting sick. But as time passes motivation to stick to the rules may run low. Whilst we obviously benefit from not contracting the Covid-19 virus, not getting sick may be unrewarding for some, as they were never sick in the first place. This lack of perceived ‘reward’, combined with potentially increasing levels of boredom could reduce people’s motivation to remain in lockdown mode. The recent confusion around where and when we can get physical exercise could further fray the edges of our desire to do the right thing. Seeing others surfing, mountain biking, and picnicking in the park creates unintentional social norms: if they’re doing it, why shouldn’t we?

“Thus far the Government’s messaging around the corona-crisis has been well thought out and on target, emphasising the pro-social and pro-active aspects of staying home and being physically distant. Kiwis will continue to need evidence that what they’re doing is working and that we’re all in this together. We may also need occasional reminders about what the alterative could be, just to keep our internal alert systems firing.

“If Level-4 is to be extended for some or all of us, that decision needs to be made as soon as possible to allow people to adjust their expectations and reduce the feelings of disappointment and anger that may naturally occur. Having a bored and grumpy population who are losing motivation is a situation the Government will want to avoid.

“It is encouraging to know that the Government is mindful of our collective mental health, with plans to release resources to support our resiliency and help us adjust post lock-down.”

No conflicts of interest.